Intermittent application of positive pressure devices (v no intervention) on lung volume in non- ventilated people with SCI who have respiratory muscle weakness | SCI Physiotherapy Clinical Practice Guidelines

	Intermittent application of positive pressure devices (v no intervention) on lung volume in non- ventilated people with SCI who have respiratory muscle weakness
P	People with SCI who are not ventilated and have respiratory muscle weakness	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.		Strong opinion statement FOR Intermittent application of positive pressure devices should be provided to improve lung volume in non-ventilated people with SCI who have respiratory muscle weakness. Clinical note: Contraindications and precautions for the use of positive pressure devices must be considered before prescribing these treatments. For example, positive pressure devices are contraindicated in conditions that include but are not limited to untreated pneumothorax, tracheoesophageal fistula and acute traumatic brain injury with increased or poorly controlled intracranial pressure. Positive pressure devices include mechanical insufflation, Intermittent Positive Pressure Breathing (IPPB), Continuous Positive Airway pressure (CPAP) and brief periods of Bilevel Positive Airway Pressure (BiPAP).
I	Intermittent application of positive pressure devices
C	No intervention	Consensus-based opinion statement Strong for (93%)
O	Lung volume (Litres)	Consensus-based opinion statement Strong for (93%)
	SUMMARY	1 RCT (see reference)		Mean difference (95% CI): Lung volume in litres 0.1 (-0.5 to 0.7) Favours intermittent positive pressure breathing
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision Serious	Indirectness Serious	Publication bias Serious

INTERMITTENT APPLICATION OF POSITIVE PRESSURE DEVICES ON LUNG VOLUME: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

INTERMITTENT POSITIVE PRESSURE FOR LUNG VOLUME: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
LAFFONT 2008	Intermittent positive pressure breathing (IPPB) V No intervention	IPPB up to 40cmH20 20mins 2 x per day 5 days per week or 2 months	C5-T6 Complete SCI <6months post injury	14/14	Lung volume (VC)	High Risk of Bias PEDro = 5/10

The Australian and NZ SCI Physiotherapy guideline committee recommends intermittent application of positive pressure devices to improve lung volume in non-ventilated people with acute SCI who have respiratory muscle weakness.

This is a consensus-based opinion statement supported by the opinions of the experts even though there is one randomised controlled trial related to this topic. However, the result of the randomised controlled trial is inconclusive preventing an evidence recommendation.

The guideline states:

Intermittent application of positive pressure devices should be provided to improve lung volume in non-ventilated people with acute SCI who have respiratory muscle weakness.

This statement was formed by considering the opinions of the experts alongside other factors. The other factors that were considered were benefits and harms, values and preferences, resource use, equity, accessibility, and feasibility. The results of the one randomised controlled trial was also taken into consideration.

This is a consensus-based opinion statement. Consensus-based opinion statements are less robust than evidence-based recommendations. They can be strong or weak. This is a strong consensus-based opinion statement which means that the guideline panel is confident they can recommend intermittent application of positive pressure devices to improve lung volume based on opinion.

To learn more about the research related to this intervention go to the clinicians tab on this website

Laffont I, Bensmail D, Lortat-Jacob S, et al. Intermittent positive-pressure breathing effects in patients with high spinal cord injury. Archives of physical medicine and rehabilitation 2008; 89: 1575-1579.